Radiation-induced changes manifested during treatment can theoretically increase the risk of local failure and alter predicted normal tissue toxicity. For this reason, a framework is necessary to assess and potentially intervene in instances of organ movement and deformation. This study assessed the potential benefits of an online and offline adaptive planning system for treatment of patients with head and neck cancer.

Materials and Methods

An adaptive framework was developed that utilized the components of a commercially-available treatment planning system (image registration, dose computation, IMRT optimization) and added software elements to support deformable organ modeling, dose evaluation in a changing patient geometry, and replanning techniques taking into consideration dose previously delivered; these tools were employed to allow simulation of different adaptation scenarios

Pretreatment CT and MRI were acquired for 16 head and neck cancer patients and, weekly MRI for each patient was performed during radiotherapy

Pretreatment CT and MRI images were fused and manually contoured according to RTOG H-0022

Weekly MRI images were likewise manually contoured, and the pretreatment MRI was propagated and conformed to the corresponding structures from the weekly MRI images to represent a 4D model of targets and clinical structures during the radiation course

IMRT was planned to meet the H-0022 dose-volume criteria, and the dose distribution corresponding to the geometry of each MRI was determined

In cases in which a PTV margin was included, CTV coverage was generally assured with online correction; however, online correction resulted in increases (up to 30%) in mean salivary gland dose and increases (up to 10%) in maximum cord dose versus the initial plan

The mixed online/offline strategy produced equivalent CTV coverage without the necessity of a PTV margin and reduced the maximum cord dose and mean salivary gland dose by 5% and 12%, respectively

Implementation of an online/offline adaptive framework can preclude the necessity of a PTV margin and reduce dose to adjacent normal tissue

Clinical/Scientific Implications

This novel online/offline adaptive framework illustrates the dosimetric importance of changes in patient anatomy during treatment. However, although dosimetric gains were achieved, the clinical relevance of these endpoints is unclear. Further study is warranted to evaluate the significance of such dosimetric improvements to justify an approach that is considerably more labor-intensive.